# InsureMO Claim API User Guide
## Introduction
InsureMO Claim API platform delivers comprehensive configuration capabilities, making the claims more flexible and powerful. It is applicable to all partners and tenants. InsureMO Claim API is a comprehensive claim management platform designed to empower partners with flexible, scalable, and efficient claim processing capabilities. We provide **5 major capabilities** to help partners build and customize their claim solutions rapidly.
---
### Core Capabilities
#### 1. API Capabilities
We provide two categories of APIs to support diverse integration needs:
| API Category | Description |
|--------------|-------------|
| **Business Service API** | Core claim business operations and services |
| **Business Orchestration API** | Workflow orchestration and process management |
**Key Features:**
- **Dynamic Field**: Support for flexible field definitions and extensions
- **Dynamic Model**: Adaptive data models that can be customized per business requirements
---
#### 2. Configuration Capabilities
We provide a comprehensive series of configurations to support the entire claim process, significantly reducing partners' implementation costs:
| Configuration | Description |
|---------------|-------------|
| **Claim Matrix** | Product, coverage, and reserve configuration (V1 & V2) |
| **Claim Process** | Configurable workflow and task definitions |
| **Batch Process** | Batch FNOL and bulk data processing |
| **Rule Engine** | Business rules and validation logic |
| **Code Table** | Standardized codes and reference data |
| **Calculation Configuration** | Factors, formulas, accumulators, and relativities |
| **Claim Authority** | Permission and authority management |
| **Bill Configuration** | Bill items and groups for health insurance |
---
#### 3. Integration Capabilities
We provide robust integration capabilities to enable partners to achieve quick and seamless integration:
| Capability | Description |
|------------|-------------|
| **Integration Interface** | Standardized interfaces for external system integration |
| **Process Framework** | Framework for custom process extensions |
| **Webhook** | Event-driven notifications and callbacks |
| **SDK Support** | Software Development Kit for rapid development |
These capabilities enable partners to:
- Integrate with existing core systems
- Extend claim workflows with custom logic
- Receive real-time event notifications
- Build custom integrations with minimal effort
---
#### 4. UI Capabilities
We provide sample UIs that partners can use as a foundation for customization:
**Available Sample UIs:**
- Task Query
- Claim Search
- Claim Reassignment
- New and Reopen
- Task Monitor
- Batch FNOL
- Diary Task Management
- Party Management
**Customization Options:**
- Use sample UIs as templates and customize based on business needs
- Develop completely new UIs independently
- Leverage our UI framework and components
- Responsive design for web and mobile access
---
#### 5. Template Capabilities
Partners can customize communication templates according to their business requirements:
**Supported Template Types:**
- Letters
- Emails
- SMS
- Push Notifications
**Pre-defined Trigger Points:**
| Trigger Point | Description |
|---------------|-------------|
| FNOL Submit | Triggered when First Notice of Loss is submitted |
| Registration Submit | Triggered when claim registration is completed |
| Calculation Submit | Triggered when claim calculation is submitted |
| Settlement Submit | Triggered when claim settlement is submitted |
| Task Assignment | Triggered when tasks are assigned to users |
| Task Overdue | Triggered when tasks exceed due date |
And more customizable trigger points...
**Template Features:**
- Dynamic content insertion (claim data, policy data, etc.)
- Multi-language support
- Customizable branding and formatting
- Conditional content based on business rules
---
### Partner Benefits
By leveraging these 5 core capabilities, partners can:
| Benefit | Description |
|---------|-------------|
| **Rapid Deployment** | Accelerate time-to-market with pre-built configurations and APIs |
| **Cost Efficiency** | Reduce implementation and maintenance costs with configurable solutions |
| **Flexibility** | Adapt to diverse insurance products and business models |
| **Scalability** | Handle growing claim volumes with enterprise-grade architecture |
| **Customization** | Tailor solutions to specific business requirements |
| **Integration Ready** | Connect seamlessly with existing systems and workflows |
---
### Technology Architecture
```
┌─────────────────────────────────────────────────────────────────┐
│ InsureMO Claim API │
│ Platform │
├─────────────────────────────────────────────────────────────────┤
│ │
│ ┌─────────────┐ ┌──────────────┐ ┌──────────────┐ │
│ │ API │ │ Configuration│ │ Integration │ │
│ │ Capabilities│ │ Capabilities │ │ Capabilities │ │
│ └─────────────┘ └──────────────┘ └──────────────┘ │
│ │
│ ┌─────────────┐ ┌──────────────┐ │
│ │ UI │ │ Template │ │
│ │ Capabilities│ │ Capabilities │ │
│ └─────────────┘ └──────────────┘ │
│ │
├─────────────────────────────────────────────────────────────────┤
│ Core Platform Layer │
│ • Claim Matrix • Rule Engine • Process Framework │
│ • Authority Mgmt • Calculation • Data Management │
└─────────────────────────────────────────────────────────────────┘
↓
┌─────────────────────────────────────────────────────────────────┐
│ Partner Applications │
│ • Easy Claim • Custom UIs • External Systems │
│ • Mobile Apps • Portals • Core Banking │
└─────────────────────────────────────────────────────────────────┘
```
---
## Configuration
- Claim Matrix V1
- Claim Matrix V2
- Bill Configuration
- Calculation Configuration
- Claim Authority
- Claim Mode
- Claim Process
- Catastrophe Management
- Blocklist Management
- Schedule Management
- Assignment Approach
- ICD Management
- CPT Management
- Upload Monitor
### Claim Matrix V1
#### Product Management
This product configuration function module enables the configuration of products, coverages and reserves, etc.
1. Click **Claim Configuration** > **Claim Matrix V1** > **Product Management** menu.
2. On the left, the **Product Tree** serves as a directory of existing products and supports fuzzy query for Product Tree.
3. On the right, the **New Product** supports three methods for product creation.
##### Add New Products or Update Old Products
###### Product
1. Click **New** in New Product section, and the right section will switch to 'New Product Configuration' page.
2. Click a product from the Product Tree on the left, and the right section will switch to the 'Selected Product' page.
3. Click **Next** or **Coverage** on the navigation bar, and the right section will switch to the 'Coverage' page.
###### Coverage
The Coverage page includes three sections: Product Process, Coverage and Search Result.
1. Click **Search** to query all coverages under the product filtered in the coverage section. The results will be displayed in Search Result section.
2. Click **Reset** to reset filter conditions in Coverage section.
3. Click **New** to add a new coverage, and the right section will switch to the 'New Coverage' Page.
a. Enter coverage information and click **Save**. The coverage will be displayed on 'Coverage' page.
b. The system will generate default reserve record based on the Subclaim Type-Coverage-Reserve Type, which includes all types of Reserve Type.
4. Click  to update the coverage information.
5. Click  to delete the coverage, along with its related sub-coverages and default reserve records.
6. Click **Back**, and the right section will switch to the 'Product' page.
7. Click **Next**, and the right section will switch to the 'Default Reserve' page.
###### Default Reserve
The Default Reserve page includes three sections: Product Process, Default Reserve, and Search Result.
1. Click **Search** to query all reserves associated with the current product's coverage based on the condition of Default Reserve. Search results will be displayed in the Search Result section.
2. Click **Reset** to reset all conditions within the Default Reserve section.
3. Click **Back**, and the right section will switch to the 'Coverage' page.
4. Click **Save**, and the system will save the information. For a healthy product, a **Next** button will appear. Upon Clicking it, the right section will return to the 'Calculation Factor Config' page.
##### Copy Product
1. Click **Copy** in New Product section, and the system will display 'Copy Product' page.
2. Search the existing products of the system through the query box. Select and copy the product information, or click **Cancel** to close the page.
3. Select the product and click **submit**, then the system will enter the 'New product' page. Copy the selected product information to a new product, including product, coverage, default reserve, except product code, product name and product version.
note
The submission of the copy page does not complete the product copy process. You must proceed to the 'New product' page, enter product code, product name and product version, and click **Next** to complete the process. The copied product information, including product, coverage, default reserve, will be saved to the database.
##### Upload Product
Click **Upload** in New Product section, and the system will display the 'Upload' page.
#### Download Product
1. Click **Claim Configuration** > **Claim Matrix V1** > **Download Product** menu.
2. Search the existing products of the system through the query box. And select one or more products for download.
3. After selecting one or more products,
a. Click **Download**, and the system exports all data of the selected products as an excel file.
b. Click **Export Deployment Package**, and the system exports all data of the selected products as a zip file(This function is only available in [MC environment](#what-is-mc-environment)).
### Claim Matrix V2
To address the increasingly complex claim requirements across product lines, we have made some updates for both APIs and claim configurations. It focues on three areas: adding a new calculation tool, supporting full-scale claim calculation instead of incremental claim calculation, enabling parallel tasks based on full-scale claim calculation and the API changes to support the new features
1. Build a new calculation tool. We have replaced the built-in rating function of GIMO with a new configuration tool. This tool can be used to configure the calculation formulas and related calculation logic for claim calculation.
2. Build a new Claim Matrix version. A new Claim Matrix version has been introduced to support product configuration with new calculation rules.
3. Support full-scale claim calculation. Multiple calculations requires the manual inclusion of incremental amounts as new factors. For example, if the initial calculated amount is 1000, and an additional claim of 500 is needed, the system requires restarting the calculation. The second calculated amount is 500, which means the total amount is 1500. The system now preserves the total in the latest version. For example, while the initial calculation may yield 1000, we directly input 1500 for the second calculation, with the system recognizing this as the final amount.
The updates will not affect any existing functions, ensuring the default rules and existing calculation rules remain unchanged. We have relevant parameters to control. For tenants continuing to use the current version, no additional configuration is required.
#### Product Management
1. Click **Claim Configuration** > **Claim Matrix V2** > **Product Management** menu.
2. On the left, the **Product Tree** serves as a directory of existing products and supports fuzzy query for Product Tree.
3. On the right, the **New Product** supports three methods for product creation.
##### Coverage Category
The system maintains coverage category for each product line, combines some similar coverages as a coverage, and configures the relationships with cause of loss, subclaim type, reserve type.
##### Add New Products
###### Product
1. Click **New** in New Product section, then the right section will switch to the 'New Product Configuration' page.
2. Click a product in the left Product Tree, then the right section will switch to the 'Selected Product' page.
3. Add function switch in product information, controling bill item and pre-authorization.
4. Click **Next**, then the right section will switch to the 'Coverage' page.
###### Coverage
1. Factor tab: mainly maintains information on Cause of Loss, Subclaim Type, Reserve Type, Limit Category and Coverage Category.
2. Bill item tab: If the switch of bill item in product info is selected, the tab will be displayed. It maintains the relationship between coverage and bill item. The bill item can be selected from what we maintained in Bill Configuration->[Bill Item](#bill-item) menu.
3. Calculation Factor tab: It maintains the claim factors for the coverage. The selected factors can be displayed in calculation UI, and the input values can be used to do the calculation. The factors can be selected in Calculation configuration->[Factor](#factor) menu.
###### Coverage Calculate Config
1. Change the UI display and add tab to configure the calculation sequence for coverages, instead of adding a column to select cause of loss in table
###### Coverage Basic Payment
1. Configure the basic payment for the coverage, instead of configuring calculation formula in rating.
2. Select the relativity for different formula: The relativity can be selected from what we maintained in Calculation configuration->[Relativity](#relativity) menu.
3. Select formula: The formula can be selected from what we maintained in Calculation configuration->[Formula](#formula) menu.
###### Coverage Accutor
1. Configure accumulator for the coverage, instead of configuration limit category for coverage and the detailed accumulated logic for limit and deductible in rule and rating engine.
2. Select accumulator: The accumulator can be selected from what we maintained in Calculation configuration->[Accumulator](#accumulator) menu.
##### Copy Product
1. Click **Copy** in New Product section, and the system will display the 'Copy Product' page.
2. Search the existing products of the system through the query box. Select and copy the product information, or click **Cancel** to close the page.
3. Select the product and click **submit**, then the system will enter the 'New product' page. Copy the selected product information to a new product, including product, coverage, default reserve, except product code, product name and product version.
note
The submission of the copy page does not complete the product copy process. You must proceed to the 'New product' page, enter product code, product name and product version, and click **Next** to complete the process. The copied product information, including product, coverage, default reserve, will be saved to the database.
#### Product Upload Download
1. Click **Claim Configuration** > **Claim Matrix V2** > **Product Upload Download** menu.
2. You can select between the common products and accumulator product using radio buttons for upload and download, with the common product option set as the default selection.
##### Upload Product
Click **Upload**, and the system will display 'Upload' page.
##### Download Product
1. Search the existing products of the system through the query box. And select one or more products you want to download.
2. After selecting one or more products,
a. Click **Download**, and the system exports all data of the selected products as an excel file.
b. Click **Export Deployment Package**, and the system exports all data of the selected products as a zip file (This function is only available in [MC environment](#what-is-mc-environment)).
### Bill Configuration
#### Bill Item
Based on product claim rule, each issued coverage will pay for specific bill items. This function is built to manage bill items and often utilized for health products.
1. Click **Claim Configuration** > **Bill Configuration**> **Bill Item** menu.
2. Click **New**/**Edit** to add/edit a Bill Item record.
3. Input query conditions, and click 'Search' to query the bill item records.
4. Click **Upload**, multiple bill item records can be maintained through one operation.
5. Click **Export Deployment Package**, and the system exports all data of bill items as a zip file (This function is only available in [MC environment](#what-is-mc-environment)).
6. Click the 'History' icon of a specific record in the query results to view data of other modules associated with the bill item.
7. Click the 'View' icon of a specific record in the query results to view the bill item details.
8. Click the 'Delete' icon of a specific record in the query results to delete the bill item records.
9. Click **Download**, and the system exports all data of bill items as an excel file.
#### Bill Group
In specific medical scenarios such as surgical procedures, the system generates a list of bill item. It uses the surgical as a group, and each surgical can have a group and its bill item.
1. Click **Claim Configuration** > **Bill Configuration**> **Bill Group** menu.
2. Click **New**/**Edit** to add/edit a Bill Group record.
3. Input query conditions, and click 'Search' to query the bill group record.
4. Click **Export Deployment Package**, and the system exports all data of bill groups as a zip file(This function is only available in [MC environment](#what-is-mc-environment)).
5. Click **View** icon of a specific record in the query results to view the bill group detail.
6. Click **Copy** icon of a specific record in the query results to copy the bill group details.
### Calculation Configuration (New Calculation Tool)
#### Factor
The calculation factor can be maintained in this function, EX: medical fee, admission days.
1. Click **Claim Configuration** > **Calculation Configuration**> **Factor** menu.
2. Input query conditions, and click 'Search' to query the factor record.
3. Click **New**/**Edit** to add/edit a Factor record.
4. Click **Upload**, multiple Factor records can be maintained through one operation.
5. Click **Export Deployment Package**, and the system exports all data of factors as a zip file (This function is only available in [MC environment](#what-is-mc-environment)).
6. Click **History** icon of a specific record in the query results to view data of other modules associated with the Factor.
7. Click **View** icon of a specific record in the query results to view the Factor details.
8. Click **Delete** icon of a specific record in the query results to delete the Factor records.
9. Click **Download**, and the system exports all data of factors as an excel file.
#### Relativity
The relativity can be understood as a condition field, and different rules can be set based on the condition.
1. Relativity can be used in following functions:
a. Claim Matrix-Basic Payment
b. Accumulator
c. Accutor Chain
2. Click **Claim Configuration** > **Calculation Configuration**> **Relativity** menu.
3. Input query conditions, and click 'Search' to query the relativity records.
4. Click **New**/**Edit** icon to add/edit a relativity record.
5. Click **Upload**, multiple relativity records can be maintained through one operation.
6. Click **Export Deployment Package**, and the system exports all data of relativities as a zip file (This function is only available in [MC environment](#what-is-mc-environment)).
7. Click the **History** icon of a specific record in the query results to view data of other modules associated with the relativity.
8. Click **View** icon of a specific record in the query results to view the relativity details.
9. Click **Delete** icon of a specific record in the query results to delete the relativity record.
10. Click **Download**, and the system exports all data of relativities as an excel file.
#### Formula
Used to configure the calculation formula, which can be used in Claim Matrix-basic payment, accutor formula, and accutor chain formula.
1. Click **Claim Configuration** > **Calculation Configuration**> **Formula** menu.
2. Input query conditions, and click 'Search' to query the formula record.
3. Click **New**/**Edit** icon to add/edit a formula record.
4. Click **Export Deployment Package**, and the system exports all data of formulas as a zip file(This function is only available in [MC environment](#what-is-mc-environment)).
5. Click **History** icon of a specific record in the query results to view data of other modules associated with the formula.
6. Click **View** icon of a specific record in the query results to view the formula details.
7. Click **Copy** icon of a specific record in the query results to copy the formula record.
#### Accumulator
Defines the accumulator which can used in claim matrix-coverage accutor. It’s often used to configure the limit and deductible.
1. Click **Claim Configuration** > **Calculation Configuration**> **Accumulator** menu.
2. Input query conditions, and click 'Search' to query the accumulator record.
3. Click **New**/**Edit** icon to add/edit an accumulator record.
4. Click **Export Deployment Package**, and the system exports all data of accumulators as a zip file (This function is only available in [MC environment](#what-is-mc-environment)).
5. Click **History** icon of a specific record in the query results to view data of other modules associated with the accumulator.
6. Click **View** icon of a specific record in the query results to view the accumulator details.
#### Accumulator Chain
Usually when one coverage input is relied on another coverage input, we can use this chain to build the accumulator relationship between these coverages.
1. Click **Claim Configuration** > **Calculation Configuration**> **Accumulator Chain** menu.
2. Input query conditions, and click **Search** to query the accumulator chain records.
3. Click **New**/**Edit** to add/edit an accumulator chain record.
4. Click **Export Deployment Package**, and the system exports all data of accumulator chain as a zip file (This function is only available in [MC environment](#what-is-mc-environment)).
5. Click **View** icon of a specific record in the query results to view the accumulator chain details.
6. Click **Delete** icon of a specific record in the query results to delete an accumulator chain record.
### Claim Authority
#### Claim Authority Management
Module and permissions can be modified on the Claim Authority Management page.
Used to configure the claim authority based on the picture below.
1. Click **Claim Configuration** > **Claim Authority** > **Claim Authority Management** menu to access the page which includes the Module, Permission Name, Product, and Task Authority.
2. Permission Name displays the permission name configured by the claim authority node under **URP > permission**.
3. When a permission name and module is selected by a user, the product directory tree will be displayed.
4. Check corresponding task authority and click **Submit** to successfully modify the authority.
5. Click **Reset** to reset the authority, and the system will clear the configured task authority.
#### Claim Authority Upload
1. Click **Claim Configuration** > **Claim Authority** > **Claim Authority Upload** menu.
2. **Upload**: Upload claim authority as an excel file. Click **Download** to download the detailed template.
3. **Download**: Select at least one Permission Name.
4. **Download All**: The system will download all configured authority data under all permissions and products (The template obtained is the same as the template when clicking **download**).
### Claim Mode
InsureMO Claim API supports two Claim Modes: **Claim** and **Subclaim**. Tenants can set the Claim Mode by modifying the Configuration Table - 'NewestCaseModeCfg'.
### Claim Process
#### Claim Process Management
In this module, tenants can configure task generation methods (manual or automatic), specify
whether a task requires an automatic completion and whether tasks can be configured to be parallel.
On Entry page, the system displays the latest claim workflow configuration information.
Configure the claim process based on the picture below.
1. Click **Claim Configuration** > **Claim Process** > **Claim Process Management** menu. The page displays information, including the module, Product, Task Configuration, and Version.
2. Upon selecting in the product directory tree on the left, the Task Configuration and Version will be displayed on the right accordingly.
3. Check the corresponding claim process and click **Submit** to modify the process, then the system will add a new version.
4. Click  means that the process contains this task with FNOL and Settlement as default tasks.
5. Click  to modify the information of existing claim process versions.
a. Click **Submit** to submit the modification information.
b. Click **Close** to close the page without saving anything.
#### Claim Process Upload
1. Click **Claim Configuration** > **Claim Process** > **Claim Process Upload** menu.
2. Product Tree: Users can select **Root\Product Line\Product** that has maintained process dates.
3. Button rules:
a. **Export Deployment Package**: Exports all data of the selected product as a zip file.
b. **Export Deployment Package For All**: Exports all data of all product as a zip file.
c. **Upload**: Uploads claim process data as an excel file.
d. **Download**: Exports all data of the selected products as an excel file.
e. **Download All**: Exports all data of all products as an excel file.
f. **Download Template**: Download a template.
### Catastrophe Management
1. Click **Claim Configuration** > **Catastrophe Management** menu to access a page where you can query and manage catastrophe information.
2. Input query criteria and click **Search**, then the system will display corresponding records in the search results.
3. Click **New** to add a new catastrophe record and open the 'New catastrophe' page:
4. Click  to update catastrophe information and open the 'Edit Catastrophe' page:
### Blocklist Management
Click **Claim Configuration** > **Blocklist Management** menu to access the page where you can query or add a new blocklist.
1. Input Name or Unique Number in the text box, and click **Search** to query the blocklist.
2. Click **Advance Search** hyperlink, and the system displays more independent query criteria: Name, Unique Number, Blocklist Cause, how to Process, Status, Effective Date, and Expire Date.
3. Click , and the system displays result fields. Users can select result fields (except for fields of Name) on current screen.
4. Button rules:
1)**Search**: Searches the blocklist and the system will display it in the search result.
2)**New**: Creates a new blocklist.
3)**Upload**: Opens the upload page and adds a new blocklist by uploading an excel file.
4)**Reset**: Clears all search criteria.
5)**Operation**:
a. : click it to view blocklist information.
b. : click it to edit blocklist information.
c. : click it to delete a blocklist.
d. : click it to disable the blocklist.
6)**Download**: click the button to download the search result list to the local as an excel file.
#### New\Edit Blocklist Page
Click **New** or **Edit** in blocklist management search page, and the system displays new\edit blocklist page.
The page includes two sections: Blocklist Information and Blocklist History.
1. Blocklist Information: input blocklist information in this section.
2. Blocklist History displays operation history. Upon successful submission, the system will automatically create a history record.
3. The following action buttons are available at the bottom of the page:
a. Click **Save** to save the blocklist information.
b. Click **Submit** to submit the blocklist information and return to the blocklist management search page.
c. Click **Exit** to return to the blocklist management search page.
### Schedule Management
#### Schedule Calendar
1. Click **Claim Configuration** > **Schedule Management** > **Schedule Calendar** menu to access the page where you can query and operate your schedule information for both yourself and sub-users.
2. Click **Calendar**, you can see the schedule information of chosen day or month.
3. Click **Operation Log** to open a window for query Operation log of shift schedule information.
4. Click **Upload** to open a window for uploading files. You can upload files of specified type to update the schedule information.
5. Click **Download** to open a window for downloading files. You can download the schedule information in the date range you selected.
#### Schedule Configuration
1. Click **Claim Configuration** > **Schedule Management** > **Schedule Configuration** menu to access the page where you can operate the schedule information for both yourself and sub-users.
2. Click **Submit** to update and save your operation of the schedule information.
3. Click **Search** to query the schedule information of current week.
4. Click  to open the 'Shift Management' page. For more information, refer to [Shift Management](#shift-management) in the following picture:
5. **Operation Log, Upload, Download**: These three buttons are consistent with the functions on 'Schedule Calendar' page.
#### Shift Management
1. Click **Claim Configuration** > **Schedule Management** > **Shift Management** menu to access the page where you can query and operate Shift Information.
2. Click **Search** to query Shift Information based on conditions.
3. Click  to update Shift Information of current line.
a. After Click , then this record becomes modifiable except Shift Code.
b. This operation changes from  to  and .
c. Click  to save the modified records.
d. Click  to cancel the modification.
4. Click **Add** to add a new record in the first line of the record.
a. Click  to save a new record.
b. Click  to cancel the adding.
### Assignment Approach
1. Click **Claim Configuration** > **Assignment Approach** menu to access the page where you can configure the assignment modes supported by tasks when manually/automatically generating the task.
2. Manual Assignment Approach: Select the supported types when adding a task manually. Multiple options can be checked. Click again to cancel the selection.
3. Automatic Assignment Approach: Support three assignment modes: Manual, Pool, and Automatic. You can choose one mode for automatically generated task of this claim type.
4. Maximum: It is a factor in the automatic task assignment rule. When a user's task number reaches the Maximum configuration value, they will be excluded from automatic task assignments.
### ICD Management
1. Click **Claim Configuration** > **ICD Management** to access the page where you can configure the ICD informaiton.
2. Click **Search** to search records based on the specified criteria and display the results.
3. Click **New** to open the new ICD information page.
4. Click **Upload** to open the upload interface.
5. Click  to open the edit page where the ICD information of the current line can be modified.
6. Click **Download** to download the excel file.
7. On the ICD new\edit page, all required ICD information must be completed.
### CPT Management
This function is used to maintain the category about CPT. Through the classification of CPT, precise management and scenario-based application of codes are achieved.
CPT is used to maintain the Current Procedural Terminology. It is a set of standardized medical procedure coding system developed by the American Medical Association (AMA). It is primarily used to describe operations such as diagnosis, treatment, and surgery in medical services.
### Upload Monitor
1. Click **Claim Configuration** > **Upload Monitor** menu.
2. Enter searching criteria to get the upload history.
3. Currently, several types of file upload management are supported: blocklist, schedule, batch report, etc.
4. If the data uploaded has failure records, the upload status will be failed and click the download icon  to download failure data.
## Q＆A
### Q1: What kind of catastrophe information can I maintain in the Catastrophe Management menu?
A: You can maintain details like catastrophe code, name status. This info is used to tag claims tied to large-scale disasters.
### Q2: How to link the catastrophe info relevant claim cases?
A: When creating a claim, we can select catastrophe which maintained in Catastrophe Management menu.
### Q3: How does the system apply the blocklist to claim processing?
A: We can validatE the claim party during the claim processing.
EX: when we do the payment, we need fill the payee, we can validate whether the payee is a blocklist and based on blocklist management info, to inform with a block or warning message.
### Q4: Can I view my team members’ schedules through the Schedule Calendar?
A: Yes, in this menu, you can view the calendar of your self and your team member.
### Q5: As a manager, can I set different schedule for different team members via the Schedule function?
A: Yes, in the schedule management menu, you can set the work shift for your team member, EX: vacation, work, etc.
The shift has a management menu, we can maintain different shift with different time period.
### Q6: What's the usage for the schedule?
A: It usually work for the task auto assignment rule, we can configure whether the user is on work or vacation, when system apply the auto assignment rule, if someone is on vacation, then will not assign task to him.
### Q7: How to understand the feature of claim matrix?
A: This is a feature used to maintain the claim relationship of insurance products.
We can maintain product info, coverage info, and for each coverage, we can maintain the relationship with claim factors, cause of loss, sub-claim type, reserve type, bill item and calculation factor, all these info will be auto filtered in the claim processing.
And also in the newest claim matrix V2 version, we can also support maintain basic payment and accutor for each coverage and will be used in claim calculation.
### Q8: What is the relationship between Bill Group and Bill Item?
A: A Bill Item is a specific billing entry (e.g., "bed fee," "surgery fee"), while a Bill Group is a category of related Bill Items (e.g., "Surgery" includes surgical fees, anesthesia fees). You must first maintain Bill Items, then link them to the corresponding Bill Group.
### Q9: How to configure the claim authority?
A: System provide the claim authority menu, we can maintain claim authority by each permission.
The permission we get from URP and URP can maintain the relationship between user, role and permission.
### Q10: What's the claim process?
A: InsureMO Claim API provide a configuration feature named 'Claim Process Management', we can use this feature to define different claim process flow for different products.
The main process include FNOL, Registration, Investigation, Appraisal\Appraisal Approval, Document, Calculation\Calculation Approval, Settlement\Settlement Approval.
Except for FNOL and Settlement, all other tasks can be controlled through configuration to determine whether they need to be generated and whether they are generated automatically or manually.
### Q11: What task assignment types are supported?
A: Types include assigning tasks to a shared pool (team members pick tasks), manual assignment, or auto-assignment (based on predefined rules like workload, user status, user authority and user worktime).
### Q12: What is ICD info, and why maintain it?
A: ICD (International Classification of Diseases) codes classify medical conditions. Maintaining them helps standardize diagnosis records and validate claim eligibility (e.g., linking codes to covered conditions).
### Q13: Can I search ICD codes when processing claims?
A: Yes. When entering a medical claim, you can search and select the relevant ICD code from the maintained list.
### Q14: What’s the difference between CPT Category and CPT?
A: CPT Category groups related medical procedures (e.g., “surgical procedures”), while CPT refers to specific procedure codes (e.g., “appendectomy”).
### Q15: What types of uploads can I monitor via Upload Monitor?
A: Many features support maintained by excel. The upload result can be searched in this menu.
Include Blocklist, Schedule, Batch FNOL, Claim Authority, Claim Matrix, Coverage Category, Factor, Bill Item, Relativity, ICD, CPT Category, CPT.
### Q16: If an upload (e.g., Blocklist) fails in Upload Monitor, how can I resolve it?
A: We can download the error list file and check the fail reason, after correct the info, we can upload again.
## FAQ
### Can it support multiple insurance lines (e.g., P&C, life,health)?
A: Yes, it is compatible with core claim processes across P&C, life, and health lines, adapting to diverse channel business scenarios.
### Where can I find my tasks?
A: System provider two types task.
1. Workflow task, like FNOL, Registration, etc., these task can be found in claim task menu.
2. Diary task, can be understood as a reminder task, can be found in diary task menu.
### What should be done if the user does not want to claim compensation?
A: In FNOL or Registration, system provide cancel function, we can cancel the claim and case will be canceled.
### What to do if the insurance company finds that no compensation is needed after the case is registered?
A: System provide decline function, we can decline the case in calculation or settlement.
### If the case has been closed but it is found that compensation is still needed, how should it be handled?
A: We can reopen the case by reopen or add new indemnity or expense reserve, and then the case will be reopened and we can do additional payment.
### If I have completed a task, such as Investigation, but later find that the information is incorrect, is there any way to correct it?
A: Yes, system has a reopen task feature, we can find it in new and reopen menu. For Investigation, Appraisal, Document, Calculation, when we complete and want to do it again, we can reopen the task.
#### If the settlement payment has been completed and the payment information has been sent to the finance module for payment, but an error is found in the information, how should it be handled?
A: if the finance module haven't finish the payment, we can use cancel payment feature to cancel this payment and do another payment again
if the finance module already finish the payment, we can use recovery function to recovery this payment and also do another payment with correct info.
### Why can't I select the required coverage when updating the reserve?
A: First, verify that the policy includes the target coverage. If it exists, navigate to the Claim Matrix module and ensure that the Cause of Loss and Sub Claim Type configured for that coverage match the selections made in your current case. Mismatches in these configurations will prevent the coverage from being available for selection.
### What is MC environment?
A：The MC environment is a dedicated, isolated environment specifically designed for system configuration, management, and deployment preparation. It does not host live business applications or services. Administrators can safely perform operations such as product configuration and deployment package generation within this environment, and subsequently publish the final artifacts (e.g., deployment packages) to separate runtime environments. This isolation ensures that configuration activities do not interfere with operational business services, representing a critical design principle for maintaining system stability and security.